CHF

1. Background/Cultural Points:

   Cardiac Heart Failure is increasingly common in Cambodia due to: uncontrolled hypertension, MI, rheumatic heart disease or other valvular disease genetic predisposition, and increasing obesity. Patients in Cambodia often misunderstand CHF as an acute problem rather than a progressive problem and often present for the first time when symptomatic.

2. Diagnosis & Lab:

   1. A clinical syndrome characterized by signs and symptoms of intra-vascular and interstitial volume overload, or manifestations of inadequate tissue perfusion ie: dyspnea, edema, fluid overload, poor cardiac output.
   2. Clinical manifestations include: DOE, PND, dependent edema, orthopnea, cough worsening with recumbency, non-specific fatigue, elevated neck veins, hepatojugular reflux, tachycardia, rales, S3, laterally displaced PMI, and LE edema.
   3. Consider: H/H, Glucose, U/A, Creatinine, Na/K, CXR, EKG, Echocardiogram (Calmette), TSH (only if suspected/hi-risk)

3. Management/Education/Treatment:

   1. Consider NYHA Class: I Asymptomatic, II Symptomatic with moderate exertion, III Symptomatic with minimal exertion, IV Symptomatic at rest
   2. Review with patient: 1) CHF is a chronic condition; 2) consistent life-long treatment significantly reduces risk of worsening disease ; 3) good management requires the patient’s willingness to adjust his/her lifestyle and use medication as prescribed.
   3. Lifestyle Points:
      1. Reduce sodium intake. Avoid too much salty fish.
      2. Fluid restriction
      3. Self-monitoring weight (weight change of 1.5 kg/day)
      4. Change from white-rice-only diet to minimum 20% brown rice
      5. Weight loss if obese; Exercise if sedentary
      6. Smoking cessation, abstinence or moderation of alcohol use
   4. Medications (consider, if no contraindications, and based on comorbidities):
      1. NYHA Class I: Enalapril 5-10mg QD
      2. NYHA Class II: Enalapril 5-10mg QD, post MI: Atenolol 50 mg ½ to 1 BID
      3. NYHA Class III/ Class IV: Enalapril 5-10mg QD; post MI: Atenolol 50 mg ½ to 1 BID; Furosemide 40 mg QD; Digoxin 0.125-0.5 mg QD; Spironolactone
      4. Aspirin (ASA) 81mg QD. Warn regarding stomach irritation – consider GI protection prophylaxis or at follow-up.
   5. Referral: Jeremiah’s Hope or Visiting Cardiology Team List for valvular repair or pacing.

4. Follow-Up:

   1. Initial follow-up at 1 month, then q3-6 mos, then annually
   2. Monitor labs appropriately, based on medication chosen (ECG, Digoxin, Cr/K q3-12 mos if taking Digoxin).